RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01903
BRANCH OF SERVICE:  Army	BOARD DATE:  20140821
SEPARATION DATE:  20040620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63H10/Track Vehicle Mechanic) medically separated for a right knee condition.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The right knee condition, characterized as “postoperative knee pain and dysfunction,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated chronic pain, right knee, status post (s/p) anterior cruciate ligament (ACL) reconstruction  as unfitting, rated 0%, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified, but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting right knee condition is addressed below.  Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service  IPEB – Dated 20040315 | VA* - based on Service Treatment Records (STR)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Pain, Right Knee | 5099-5003 | 0% | Right Knee Disability | 5257 | NSC** | STR
Other x 0 (Not in Scope) | Other x 2 | STR
Combined:  0% | Combined:  NSC
*Derived from VA Rating Decision (VARD) dated 20051117 (most proximate to date of separation (DOS))
**Code changed to 5260 with rating 10% derived from VARD 20130903 effective 20120327 

ANALYSIS SUMMARY:

Chronic Pain, Right Knee.  The CI injured his right knee playing soccer in November 2001.  He underwent right ACL reconstruction on 26 February 2002.  He was enrolled in physical therapy after convalescence, but continued to report right knee pain.  At his 5 November 2002 follow-up, the orthopedic surgeon recorded a knee examination described in the table below.  A postoperative X-ray performed on 17 October 2003 noted appropriate healing after the knee surgery.  An orthopedic clinic visit note on 9 December 2003 recorded full knee range-of-motion (ROM), 0 to 130 degrees and no instability.  The CI reported occasional knee locking.  The examining surgeon further noted that the CI reported progressively worsening anterior knee pain and weakness that allowed unlimited walking with a knee brace, aggravated with running and wearing a rucksack or flack vest.  The examiner initiated a P3 profile and an MEB.  On the DD Form 2807-1, Report of Medical History, prepared by the CI on 17 December 2007, he reported his right knee repair was unstable and locked when bent.  The MEB narrative summary (NARSUM) examination completed by an orthopedic surgeon on 6 February 2004, 4 months prior to separation, recorded the examination in the table below.  The CI reported pain with squatting, problems with climbing and jumping, and that standing or sitting caused the knee to lock.  The NARSUM rated the pain of the right knee as constant and minimal and the orthopedic surgeon diagnosed “postoperative knee pain and dysfunction due to internal derangement of the knee with residual instability.”  The VA in its VARD dated 17 November 2005, 17 months after separation, made no reference to a separate C&P examination and cited the MEB examination and evidence of the STR.  The VARD stated the right knee condition was treated, finding only slight limitation of function with pain, lack of ligamentous instability and no X-ray evidence of boney abnormality.  The VARD then noted that in the 17 months since discharge there was no evidence of treatment for a right knee condition.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Knee ROM
(Degrees)

Ortho 18 Mo. Pre-Sep (20021105)

Ortho 16 Mo. Pre-Sep
(20030127)

NARSUM 4.3 Mo. Pre-Sep
(20040206)

Flexion (140 Normal) | 135 | 135 | 130
Extension (0 Normal) | 0 | 0 | 0
Comment | No effusion, NL pivot shift, no JLT, Lachman 1A, neg McMurray, min lat pain w/ varus stress, no instability consider P2 in 3 months | No effusion; Good quad tone; No: Lachman’s, Pivot Shift, JLT, McMurray’s, instability. Sl pain Var stress; x-ray aligned tunnels, stable HW | No:  effusion, McMurray’s, pivot shift, anterior drawer, IA Lachman’s. Ant knee pain; Goniometer utilized; Slight constant pain cited
§4.71a Rating | 0% | 0% | PEB 0% / VA NSC

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the chronic pain of the right knee using code 5099 rated analogously as code 5003, adjudicating a rating of 0%.  The PEB described the pain condition as being s/p ACL reconstruction with a resultant IA Lachman’s test (best results possible for this surgery) and described a pain rating of minimal/constant.  The VA denied service-connection for the right knee disability claim noting a lack of evidence of disability at the time of separation or requirement for treatment after separation.  After due consideration and review of the evidence, the Board determined the right knee ROM did not rise to the level for a compensable rating using code 5260 or 5261 for limitation of flexion or extension of the knee.  There was no evidence of ankylosis, lateral instability or removal of semilunar cartilage (surgical removal of a part of the cartilage cushion) to allow consideration of a rating under codes 5256, 5257 or 5259, respectively.  The Board considered rating under code 5258 (dislocated semilunar cartilage with frequent locking) due to the subjective reports of locking; however, there was no objective evidence such as report from surgery or diagnostic imaging of loose joint cartilage that could cause joint catching to permit use of this code.  The Board considered a rating using code 5003 IAW §4.59 and §4.71a and agreed there was a shortfall of full flexion by 10 degrees from normal with pain meeting the criteria for a rating of 10%.  The Board found no other appropriate codes for consideration.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on the USAPDA pain policy for rating the right knee was operant in this case and the condition was adjudicated independently of that policy by the Board.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic right knee pain condition coded 5099-5003 IAW VASRD §4.59 and §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
Chronic Pain, Right Knee | 5099-5003 | 10%
COMBINED | 10%

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20130908, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXX, AR20150004690 (PD201301903)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-01903